Acute abdominal pain and Q fever

Clinical Features and Complications of Coxiella burnetii Infections From the French National Reference Center for Q Fever

IMPORTANCE

Q fever remains widespread throughout the world; the disease is serious and causes outbreaks and deaths when complications are not detected. The diagnosis of Q fever requires the demonstration of the presence of Coxiella burnetii and the identification of an organic lesion.

OBJECTIVE

To describe the hitherto neglected clinical characteristics of Q fever and identifying risk factors for complications and death.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study conducted from January 1, 1991, through December 31, 2016, included patients treated at the French National Reference Center for Q fever with serologic findings positive for C burnetii and clinical data consistent with C burnetii infection. Clinical data were prospectively collected by telephone. Patients with unavailable clinical data or an unidentified infectious focus were excluded.

MAIN OUTCOMES AND MEASURES

Q fever complications and mortality.

RESULTS

Of the 180 483 patients undergoing testing, 2918 had positive findings for C burnetii and 2434 (68.8% men) presented with clinical data consistent with a C burnetii infection. Mean (SD) age was 51.8 (17.4) years, and the ratio of men to women was 2.2. At the time of inclusion, 1806 patients presented with acute Q fever, including 138 with acute Q fever that progressed to persistent C burnetii infection, and 766 had persistent focalized C burnetii infection. Rare and hitherto neglected foci of infections included lymphadenitis (97 [4.0%]), acute Q fever endocarditis (50 [2.1%]), hemophagocytic syndrome (9 [0.4%]), and alithiasic cholecystitis (11 [0.4%]). Vascular infection (hazard ratio [HR], 3.1; 95% CI, 1.7-5.7; P < .001) and endocarditis (HR, 2.4; 95% CI, 1.1-5.1; P = .02) were associated with an increased risk of death. Independent indicators of lymphoma were lymphadenitis (HR, 77.4; 95% CI, 21.2-281.8; P < .001) and hemophagocytic syndrome (HR, 19.1; 95% CI, 3.4-108.6; P < .001). The presence of anticardiolipin antibodies during acute Q fever has been associated with several complications, including hepatitis, cholecystitis, endocarditis, thrombosis, hemophagocytic syndrome, meningitis, and progression to persistent endocarditis.

CONCLUSIONS AND RELEVANCE

Previously neglected foci of C burnetii infection include the lymphatic system (ie, bone marrow, lymphadenitis) with a risk of lymphoma. Cardiovascular infections were the main fatal complications, highlighting the importance of routine screening for valvular heart disease and vascular anomalies during acute Q fever. Routine screening for anticardiolopin antibodies during acute Q fever can help prevent complications. Positron emission tomographic scanning could be proposed for all patients with suspected persistent focused infection to rapidly diagnose vascular and lymphatic infections associated with death and lymphoma, respectively.

Q Fever with transient antiphospholipid antibodies associated with cholecystitis and splenic infarction

We describe a case of Q fever associated with the transient presence of antiphospholipid antibodies in a 9-year-old boy presenting with acalculous cholecystitis and splenic infarction. Antiphospholipid antibodies are commonly associated with acute Q fever in adults but have previously been thought to be of little clinical significance. Recent data suggest that antiphospholipid antibodies may be responsible for certain clinical manifestations of acute Q fever.

Q fever cholecystitis in an unvaccinated butcher diagnosed by gallbladder polymerase chain reaction

Acalculous cholecystitis has been described in association with Q fever. We describe the first known case of Q fever cholecystitis diagnosed by polymerase chain reaction on gallbladder tissue. The presence of Coxiella burnetii genome in the diseased gallbladder tissue argues for direct involvement of the organism in the pathogenesis of Q fever cholecystitis.

Atypical Q fever in US soldiers

Q fever is an emerging infectious disease among US soldiers serving in Iraq. Three patients have had atypical manifestations, including 2 patients with acute cholecystitis and 1 patient with acute respiratory distress syndrome. Providers must be aware of Q fever's signs and symptoms to avoid delays in treatment.

Colecistitis alitiásica: una forma infrecuente de presentación de fiebre Q

Acute acalculous cholecystitis is a very rare clinical presentation of Q fever. We report the case of a 38-year-old man who presented with fever associated with elevation of liver enzyme levels and thickening of the gallbladder wall on abdominal ultrasonography and who was initially diagnosed with acute acalculous cholecystitis. Due to the persistence of fever and transaminase elevation despite antibiotic treatment, a liver biopsy was performed. Characteristic "doughnut" epithelioid granulomas were observed, suggesting a diagnosis of granulomatous hepatitis caused by Q fever, which was confirmed by serological methods. Treatment with doxycycline was commenced and the patient subsequently showed rapid clinical improvement, with disappearance of fever and normalization of liver enzyme levels. We review 8 cases of acute cholecystitis associated with Q fever published in the literature and stress the importance of liver biopsy in the etiological diagnosis of patients with prolonged fever and abnormal liver function tests.

Acute acalculous cholecystitis associated with Q fever: report of seven cases and review of the literature

Q fever is a worldwide-occurring zoonosis caused by Coxiella burnetii. There are various clinical manifestations of acute Q fever, of which acute cholecystitis is a very rare clinical presentation. This study reports seven cases of acute cholecystitis associated with Coxiella burnetii and reviews two other cases from the literature. All patients were admitted to hospital for fever and abdominal pain in the right upper quadrant. Abdominal echography showed a distended gallbladder with biliary sludge without concrements in eight cases and with a single stone in one case. Diagnosis was made by specific serological investigation (microimmunofluorescence assay) for Coxiella burnetii. All nine patients were cured, six after laparoscopic cholecystectomy and three with antibiotics only. Histological examination of the gallbladders showed inflammation in five cases, although Coxiella burnetii was not detected by immunohistochemistry. The results show that laboratory investigations in patients admitted to hospital for symptoms consistent with acute acalculous cholecystitis should include a systematic search for Coxiella burnetii.